[Remote] Pre-Authorization Nurse at Humana

Kentucky, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Licensed Registered Nurse (RN) in the state of Kentucky with no disciplinary action and ability to hold licenses in multiple states without restriction
3+ years of experience as a nurse in a clinical setting
Strong proficiency with MS Office Suite (Word, Excel, Power Point)
Experience with the development and implementation of policies and procedures

Responsibilities

Reviews prior authorization and retro requests for appropriate care and setting, following guidelines and policies
Approves services or forwards requests to the appropriate stakeholder
Completes medical necessity and level of care reviews for requested services using clinical judgment
Refers to internal stakeholders for review depending on case findings
Educates providers on utilization and medical management processes
Enters and maintains pertinent clinical information in various medical management systems
Makes decisions regarding own work approach/priorities and follows direction
Meets quarterly in Louisville, Ky office for meetings

Skills

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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